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        <p>听网课。手机上码的。点评老师。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/01.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/02.jpg"><br>四位医生报告病例，张琛老师点评。<br>第一个病例，上颌4，三根管。<br>显微镜下开髓。用vdw的c锉疏通至根管全长。<br>细弯根管，用单尖法根充。<br>用高嵌体修复。六年复查良好。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/03.jpg"><br>看得到才能做得到。逐步疏通根管，而不是一下到全长。冠修复方式多样化。<br>点评:<br>资料较完善，观察时间较长。<br>根尖片上有哪些迹象表明根管形态是复杂的?<br>如果根管影像在牙根中段或中下段消失/分叉，提示可能有多根。<br>诊断，牙髓炎根尖周炎一定要有明确的感染来源。最好有初诊口内照。检查探痛要明确是否露髓。温度试验要用教科书的规范描述。<br>显微镜下开髓的原因?减小磨除牙体组织，更加精准。<br>锉要预弯。重度弯曲还是用小号手锉建立直线通路。需适当去除牙本质领。<br>开髓之前就降牙合，然后才做根测。<br>前磨牙、隐裂牙不太适合做髓腔固位冠。可以考虑纤维桩核全冠修复。<br>使用高浓度3%的次氯酸钠，可能影响工作长度确定。可以先用生理盐水进行置换，再根测。<br>冠根一体化，牙髓病医生也要关注冠部修复。<br>第二个病例 右下侧切牙根管不通转诊<br>检查有侧穿。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/04.jpg"></p>
<p>髓腔有钙化团块，用超声去除，疏通至根尖。用单尖法根充，iRoot BP plus修复侧穿。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/05.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/06.jpg"><br>侧穿的地方做个小手术把多余的材料去除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/07.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/08.jpg"><br>做内漂白。<br>根尖病变大小不是拔牙的理由。<br>侧壁穿孔也不是拔牙理由。<br>对天然牙保存的敬畏。<br>点评<br>主诉按三要素来写。详细的可以写到现病史。<br>对单颗牙最需要的是根尖片。全景和大视野cbct不太必要，小视野cbct更能发挥导航作用。<br>为何根尖病变集中在远中侧方?如果有瘘道或瘘管一定要详细描述。<br>诊断要按较重的来。坏死+根尖周炎，诊断根尖周炎就行啦。<br>侧穿对测长度有影响吗？用5%次氯酸钠冲洗会不会从侧穿那里出去?为嘛用双氧水终末冲洗?慎用双氧水。<br>用BP plus修补侧穿孔，超充了。其实可以考虑从牙根外面翻瓣后进行修补。超充后不及时去除对骨组织愈合还是有影响。<br>穿孔是在骨下的，已经用超声去除肉芽了。穿孔是两个月前外院做的。<br>非手术和手术治疗是两条腿，不能偏废。<br>第三个病例 左上第一磨牙根管再治疗<br>左上6根管治疗加纤维桩核冠修复，颊侧瘘道，遗漏mb2。<br>进行再治疗。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/09.jpg"><br>初治失败原因:遗漏MB2。<br>点评<br>牙体牙髓医生再治疗病例占多数。要先练思路，再练技术。<br>当有瘘道时一定要分析来源。<br>牙周探诊要明确位置。再治疗最担心牙根纵裂。如果牙根纵裂做再治疗，一定失败，很麻烦。如怀疑，需印证或排除。<br>两年还没冠修复。<br>牙周不好是大问题。<br>探诊未发现窄深的牙周袋。<br>第四个病例 七根管牛牙症<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0222-csses/10.jpg"><br>难度:钙化，变异根管形态，改良根充术。修复方案?<br>发生率不高，但要有相关知识储备。<br>点评<br>病例较复杂。<br>主诉有疼痛史，根尖片未见明显的感染来源。要仔细分析感染来源。<br>牛牙症更适合用热牙胶充填。对侧同名牙有无这种情况?<br>CBCT不能作为常规检查手段，选择性使用。<br>冠方修复，考虑冠方和对颌情况。考虑髓腔固位冠。牙合面采用对接方式。<br>最后张琛老师分享病例报告中的一些问题<br>1.病例资料不全/不当<br>如使用显微镜需有髓底照片。口内有窦道应拍照记录。<br>单颗牙常规用根尖片。其余选择性使用。<br>复查常规用根尖片。<br>2.资料质量不佳<br>根尖片质量，加日期，多根牙建议多角度投照。<br>显微镜髓底照片，清晰，聚焦。口镜位置，角度。灯光。<br>口内照，注意清晰，聚焦。用单反别用手机。要用相关器材。<br>cbct要截图，看想反映哪个部分。<br>不要在图片上画线。<br>3.病历书写不规范。<br>全面，准确，规范，依据规范。牙位表达和标点符号要规范。<br>4.治疗方案不恰当<br>5.治疗存在缺陷<br>6.病例ppt制作和讨论要点<br>字太多<br>重点突出，简洁清楚。<br>主要通过图片说明。<br>讨论是病例的重点，要围绕病例来讨论。<br>7.病例选择无代表性<br>8.不认真<br>病例报告评价<br>病例展示<br>治疗质量<br>疑难性<br>临床意义<br>汇报表现<br>答疑<br>选择玻璃陶瓷而不是氧化锆:对对颌磨耗较小。<br>微创:别让患者做再治疗也是微创。<br>第二个病例根尖暗影在远中的原因?根尖孔开口远中，前牙拥挤，病变向阻力小的区域发展。<br>牙外伤的两个结局:牙髓钙化，牙内吸收。<br>侧穿止血:用止血剂压即可，关键把肉芽去除干净。<br>较深的穿孔:在穿孔下，用热牙胶根充，穿孔上用显微镜，iRoot bp plus修补。若太深，考虑根尖屏障，根尖手术。<br>颈部穿孔较好修补，但预后最差。根尖部穿孔较难修补，但预后最好。成功关键:感染控制+良好封闭。<br>纤维桩的去除，用超声，显微镜下进行。确保磨除方向与桩的方向一致。保证超声作用在桩上。用根管吸引器更好。术前片测量桩的长度以供参考。<br>选择再治疗而不是根尖手术的原因:综合考虑。权衡。一般首选再治疗，存在一些复杂情况时才选择根尖手术。<br>纤维桩的取出比金属桩难。用超声要及时冲洗保证视野。<br>牛牙症病例选择冠部修复的方式。全冠壁太薄。全牙尖覆盖或直接修复。<br>病例讨论是专科培养最重要的内容。要认真准备并努力分享。<br>感谢各位老师!感谢滨大读书会!</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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